|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
IP
|
$111.59
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.20 |
| Max. Negotiated Rate |
$83.69 |
| Rate for Payer: Adventist Health Commercial |
$22.32
|
| Rate for Payer: Cash Price |
$61.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.67
|
| Rate for Payer: Heritage Provider Network Senior |
$51.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.90
|
| Rate for Payer: Multiplan Commercial |
$83.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.95
|
|
|
DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE [186293]
|
Facility
|
OP
|
$111.59
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.20 |
| Max. Negotiated Rate |
$121.81 |
| Rate for Payer: Adventist Health Commercial |
$22.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$94.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$83.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.81
|
| Rate for Payer: Blue Shield of California Commercial |
$46.78
|
| Rate for Payer: Blue Shield of California EPN |
$46.78
|
| Rate for Payer: Cash Price |
$61.37
|
| Rate for Payer: Cash Price |
$61.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$94.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.85
|
| Rate for Payer: Dignity Health Senior |
$94.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.67
|
| Rate for Payer: Heritage Provider Network Senior |
$51.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$39.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$53.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.11
|
| Rate for Payer: Multiplan Commercial |
$83.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.64
|
| Rate for Payer: TriValley Medical Group Senior |
$44.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$94.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.85
|
| Rate for Payer: Vantage Medical Group Senior |
$94.85
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
IP
|
$139.57
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.26 |
| Max. Negotiated Rate |
$104.68 |
| Rate for Payer: Adventist Health Commercial |
$27.91
|
| Rate for Payer: Cash Price |
$76.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$64.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.62
|
| Rate for Payer: Heritage Provider Network Senior |
$64.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.89
|
| Rate for Payer: Multiplan Commercial |
$104.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$50.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.21
|
|
|
DIP-PERT-TET-POLIO-HIB(PF) 15 LF-20 MCG-5 LF-62 DU-10MCG/0.5 ML IM KIT [227486]
|
Facility
|
OP
|
$139.57
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.26 |
| Max. Negotiated Rate |
$309.33 |
| Rate for Payer: Adventist Health Commercial |
$27.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$74.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$95.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$118.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$76.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$104.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$309.33
|
| Rate for Payer: Blue Shield of California Commercial |
$116.18
|
| Rate for Payer: Blue Shield of California EPN |
$116.18
|
| Rate for Payer: Cash Price |
$76.77
|
| Rate for Payer: Cash Price |
$76.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$64.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$118.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.63
|
| Rate for Payer: Dignity Health Senior |
$118.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.62
|
| Rate for Payer: Heritage Provider Network Senior |
$64.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$195.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$66.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$97.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$97.70
|
| Rate for Payer: Multiplan Commercial |
$104.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$55.83
|
| Rate for Payer: TriValley Medical Group Senior |
$55.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$50.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$118.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.63
|
| Rate for Payer: Vantage Medical Group Senior |
$118.63
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
DIPYRIDAMOLE 25 MG TABLET [2528]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 64980-133-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Senior |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
DIPYRIDAMOLE 75 MG TABLET [2530]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 64980-135-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
DIPYRIDAMOLE ORAL SUSPENSION COMPOUND 10 MG/ML [4080265]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0802-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Senior |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.54
|
| Rate for Payer: Heritage Provider Network Senior |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Senior |
$2.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
NDC 0025-2752-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
|
|
DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE [2535]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 0093-3127-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Senior |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.07 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Senior |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
|
|
DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
NDC 0025-2762-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.07
|
| Rate for Payer: Blue Shield of California Commercial |
$4.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.75
|
| Rate for Payer: Dignity Health Senior |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.73
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Senior |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Vantage Medical Group Senior |
$5.75
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 0074-6114-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68084-313-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Senior |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68084-313-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 68382-106-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 0074-6114-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.00
|
| Rate for Payer: Dignity Health Senior |
$2.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.00
|
| Rate for Payer: Vantage Medical Group Senior |
$2.00
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 68382-106-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Senior |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 27241-115-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 27241-115-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68084-313-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
|
